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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKfdW,�Ck @5202 t (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICemplets IB Trlpllests) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WFTII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9'-1 11 S`.,.3 A1ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOR �� ESS/OR APNI JZ L . C1 L� 4`Wy CRY S-V�`(-1cl1(1 'A/�,.� �2s� _Z101 Q `1 �{ � �j (�.� PARCEL SIZE/AFNI OWNER'S NAME AVT- I y &Z,t nV+�O ADORES. v7``-'�1 N• P}-,,Ls s /� ILS., ��-�'F— PHONE R CONTRACTOR 1/\'}`1 T-- LisNCAI`'Q TSS Vk.0- ADORES. DC�YIC �-1 \4I Q� .l�Jr- UC/ y (f PHONF N 5 21�,ZJ'ZZ�`I SUBCONTRACTOR `� .� Oar\L,\1•..� ADDRESS•C � -�`�C1G N� UC/7� le ` PHONE/�7 37�1"�tJ(� TYPE OF WELL/PVMP: ❑ NEW WELL 7 ❑ REPLACEMENT WELL ❑ MONFTORINO WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑R.Ptdr H.P. DEPT"PUMP BUT FT. FIRST WATER LEVEL O R YPE OF PUMP) / ❑ OVT-OF-8ERVICE WELL ❑ GEOPHYSICAL WELL/ ( ROIL BORING _ B ❑DESTRUCTION: llliii INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ] DIA.OF CONDUCTOR CASINO O ❑ DOMESTOCIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEVPVC DIA.OF WELL CASINO D ❑ PUBLIC/1.IUMCIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT BEAL INSTALLED BY ��VA 1 2 GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys ❑Ne S APPROX.DEPTH �'E-+ LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIOWDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER -� CABLE OTHER 1"MBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T189 PERMIT 19 ISSUED.1814ALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SKINATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST ICALL ��24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12J081460-3A27. COMPLETE DRAWING AT LOWER AREA PROVIDED. n�/ 109—d X�!.11Llh/V�. !"Tt7Yf4xl+�r7 T10. R?-AQ-"X-A\ r V 126]F1.CL�I�� D•t• /_/�J-1 D �� PLOT PLAN IDr.w to S-1.1 S.N. -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. !. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PIOPEM.01VIE/0 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMB. a. DIMENSIONED OL -- - �"' �@ S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INC f — N awe � i �n I � �TNixS PA {✓_ EascwsExs v�.,. .. :.._.qs fin,, PFt 2 1998 -AN J BLIC `•J(v'Iti c•ocEm slwrc euurr sl.c V0. u.SOIL—.I�'. I 0 10 SCALE 114 FEET 1"-I0' �r " SITE MAP `—E ,.� 2 L APP4.6Ifer1 Ae-Wmd By ly/,' A e! /_ _ Det. (4�'� Oroul"o-d-By �` Da. /� Pump I-PP^-tf-By/ L y/1� Dat.[1e•mwller,In vocllen BY �' � � d I'1.G Jt�Q �W O•te ACCOUNTING ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REMITTED ECK/ ASH RECEIVED BY DATE PERMITMERVICE REQUEST NUMBER INVOICE o c-/I S-41 Health Serv.-Envm 173(1/97)